The female resident described in the report suffers from high blood pressure and dementia. She has significant problems with mobility and incontinence issues. An assessment in November 2011 detected no pressure sores on the resident’s skin. Her physical impairments put her “at risk” for the development of future pressure ulcers. In the month following this assessment, the patient lost over twenty pounds while at Schurmacher. In early January of 2012, the resident developed a pressure ulcer on her lower back, near her tailbone. Over the following months, a second pressure ulcer, this a Stage II, developed in the middle of her back. These pressure sores did not heal until mid-July, and the Department of Health report notes that approximately a week after the wounds were noted to be healed, the sacral ulcer had reopened.

Although care plans were in place to prevent pressure ulcers from developing, the Department’s investigation showed no evidence that the care plans, particularly revolving around a turning and positioning intervention, were implemented. Interviews also showed that although the resident’s diet was being monitored, this monitoring was conducted in such a way so as to make determining actual nutritional intake difficult.

Developing individualized care plans on a resident by resident basis is important to the individual’s well-being. However, the creation of a care plan only indicates intent. Equally, if not more, important is the implementation of these care plans. It seems as if this second phase, the implementation of the care plans, was the catalyst for the breakdown of this resident’s skin integrity. Perhaps the pressure sores would have developed even if the facility had been more diligent in adhering to its own protocols regarding the implementation of care plans. Had this been the case, though, the facility would have been in a better position to say that it had provided necessary treatment to promote healing and prevent new sores from developing. As it was, according to the Department of Health, Schnurmacher was unable to make this claim.

A full account of Schnurmacher’s certification survey, including other deficiencies in the areas of infection control, care plans, and physician responsibilities can be found here.